USER EXPERIENCE DESIGN, INTERFACE DESIGN AND HUMAN FACTORS IN

IMPROVING ELECTRONIC HEALTH RECORDS 1

User Experience, Interface Design and Human Factor Design in Improving Electronic Health

Records

Christopher Conrad Korycki

University of San Diego

HCIN 540- Introduction to Health Care Information Management

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Abstract

This paper will explore ways UX (user experience), interface design and human factors

engineering involved in design and implementation of electronic health records helps to improve

the experience for users and mitigate errors and unforeseen consequences. In the last decade or

so the proliferation and incentivized use of electronic health records and their seeming lack of

good user experience design have generally made their actual use by practitioners cumbersome

at best and a threat to patient safety at worst. Some investigations are made into why EHRs are

generally so poorly designed, identification of the complexities and challenges that face

developing for EHRs and some potential solutions and possibilities for better user centered

design are proposed.

Keywords: EHR, Electronic Health Records, User Experience Design, Interface Design
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Introduction:

This paper aims to research and explore the impact user experience design, interface design

and human factors engineering have on the use of electronic health records and their effect on

ease of use, adaptation and implementation of use, and mitigation of errors and unforeseen

consequences for the user and if this translates to better patient care outcomes.

While there is a lot of information about electronic health records there is not much about

user experience design, the various interface designs of EHR systems and the human factors

involved in the use of these systems.

Can a better, more intuitive interface make the adoption, use and outcomes of EHRs more

favorable for both the user and patient? This topic is prescient as EHRs are rapidly evolving from

beyond desktop and laptop screens to tablets, phone size displays to eventual augmented reality

and virtual reality interfaces. (Samsung Gear, Oculus Rift etc.) which require more customized

and streamlined interfaces beyond the clunky, tedious Windows-based EHRs that exist today.

And can better-designed interfaces ultimately reduce errors and increase patient care outcomes?

What are the barriers, challenges and complexities to EHR user interface development and are

there any potential solutions in developing better user centered design?

Defining and Positioning:

Before delving into the intricacies of interface design within health informatics electronic

health record software systems I would like to first elucidate upon and define concretely some of

the main terminology that will be discussed in this paper as well as then position those terms

within the context of the problem that will be examined.

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Firstly, everything examined and delineated within the realm of this paper lies within in the

field of health information technology. Health Information technology is defined as “information

technology information applied to health care. It supports health information management (itself

a branch of HIT), computerized systems and the secure exchange of health information between

consumers, providers, payers and quality monitors. “ (“Health Information Technology,”n.d)

“Health informatics is a (also called health care informatics, healthcare informatics, medical

informatics, nursing informatics, clinical informatics, or biomedical informatics) is a

multidisciplinary field that uses health information technology (HIT) to improve health care via

any combination of higher quality, higher efficiency (spurring lower cost and thus greater

availability), and new opportunities.” (“Health Informatics.” n.d) Of that definition I wish to

point out the terms higher quality, higher efficiency, and new opportunities, as the latter portion

of user centric-design shall uncover.

“The tools of health informatics and health information technology care continually

improving to bring greater efficiency to healthcare information management (also known as

HIM, which is also another branch of health care information technology) in the health care

sector.” (“Health Information Management,” n.d) I wish to stress the terms “greater efficiency”

and “continually evolving” which indicates room for continual improvement. One of the main

developments in HIT since the Department of Health and Human Services (DHHS) first

initialized a focus on increased HIT utilization in 2003 was the widespread adoption and

utilization of electronic health records, commonly referred to “EHRs”. (Niles, 2015 p. 261) The

Institute of Medicine (IOM) broadly defined the EHR to accomplish three goals: to facilitate the

collection of longitudinal data on a person’s health, immediate electronic access to this

information and establishment of a system that provides decision support to ensure the quality,
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safety, and efficiency of patient care. (Niles, 2015 p. 261) I would like to stress the third goal in

this paper.

Now that we have established where health care informatics, within the greater HIT field, is

concerned to a large degree with design as well as efficiency, and that EHRs, as one of the main

tools to accomplish this efficiency, have now proliferated greatly since 2003 and are now

standard practice (for better or for worse) I now would like to hone in on where design fits in.

The disciplines in health informatics involves “include information science, computer

science, social science, behavioral science, management science” (“Health Informatics,” n.d) and

in the context of interface and software design cognitive science and graphic design,

usability/experience design “UX” and user interface design “UI”.

The National Institute of Health defines health informatics as "the interdisciplinary study of

the design, development, adoption and application of IT-based innovations in healthcare services

delivery, management and planning" (NLM, 2017) where I would like to draw attention to the

“design” aspect of the above.

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All interaction with a computer, tablet, smartphone, menu on a television, or any interactive

information serving as an interface between a human and a screen is in the field of human-

computer interaction (HCI). HCI is a bit of a dated term and has evolved to now encompass user

interface (UI) and user experience design. User experience design (also known as UX, UXD,

UED or XD) is defined as “the process of enhancing user satisfaction with a product by

improving the usability, accessibility, and pleasure provided in the interaction with the product”

(or software in this case). (“User Experience Design,” n.d) The key concern involving UX for

this paper is usability and thus efficiency.

In defining from the most broad perspective of health information technology through health

care informatics and user experience I wished to reiterate and reinforce the notion and belief that,

by their definitions alone technology is supposed to make the practice of medicine more

efficient. The main ubiquitous, and now mandated, interface between the patient and care

provider (be it a nurse or physician) is the electronic health record system or EHR. Modern

Healthcare, it seems, is now centered around the constant interaction of this interface. Does this

interface indeed make the patient care experience better and more efficient? And if not then what

ways, facilitated by design, can improve EHRs? The aim of this paper is to examine if current

EHR systems utilize UX design principles, and if so or not, have made the systems more useable

and efficient. If not then I wish to explore ways in which UX design principles can be applied to

EHR design to make them easier to learn, easier to use, more intuitive, faster and more efficient

therefore increasing effectiveness towards patient care.

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EHRs-Intent and Reality:

Adoption of EHRs are now commonplace due to the HITECH Act and almost all major

hospitals utilize them, if not depend on them, as the main interface between physician, nurse,

care giver and patient. According to the Department of Health and Human Services, “using

electronic health records will reduce paperwork and administrative burdens, cut costs, reduce

medical errors and most importantly, improve the quality of care.” (HHS, 2017) From the birds-

eye view official governmental perspective EHRs are supposed to make the process of providing

health care easier, more streamlined and more efficient due to corralling all records into one

digital repository, thus eliminating the need for endless and needless searching for files and also

standardizing all input into that file thus eliminating the age old problem of attempting to

decipher a physician’s notoriously indecipherable scrawl. This, in theory, seems useful enough,

but is this the realty in the field?

There have been hundreds of studies about the advantages of EHRs. And many positive

results abound. “One VA study estimates its electronic medical record system may improve

overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost

of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.” (Evans)

“A 2014 survey of the American College of Physicians member sample, however, found that

family practice physicians spent 48 minutes more per day when using EMRs. 90% reported that

at least 1 data management function was slower after EMRs were adopted, and 64% reported that

note writing took longer. A third (34%) reported that it took longer to find and review medical

record data, and 32% reported that it was slower to read other clinicians' notes.” (McDonald)
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So it is clearly established that EHRs are now the norm and that, in theory, their near

ubiquitous adoption is supposed to make health care more efficient and thus increase patient care

and outcomes. In researching EHRs I also wanted to study the most widely used systems. In

surveying my colleagues who work in some of the major hospitals in the Chicagoland area

(University of Chicago Medicine, Northwestern University Medicine, Rush just to name a few)

the dominant EHR names was EPIC. In researching a bit more the top EHRs today per number

of users are (in descending order): eClinicalworks, Epic, McKesson, Care360, and AllScripts

with Cerner and GE Healthcare closely following. (Top EHR Software) A comparative analysis

of each would simply be an impossibility with direct access to each (at immense cost) and just

interviewing nurses, doctors, and users about the pros and cons of each would great insights but

would all pretty much convey the same fact (as my colleagues did to me): EHRs are a pain and

struggle to work with on a daily basis and all have a tremendous amount of room for

improvement.

This seems to be the sentiment from all the research I have encountered on the subject. My

initial paper thesis was to examine if good UX, or user experience design, would improve patient

outcomes and overall patient experience and care, but from the research I have garnered, EHRs

are so behind in design and so overly complex that they actually hinder the patient experience

and make the health care process and experience less efficient. It seems that poor usability is an

across the board factor in EHRs. Thus I set out to find out and elucidate why EHRs are so

derided and difficult to use and why their usability is so poor.

In a recent article from 2016 CMS Ambassador Andy Slavitt stated “The health IT industry

has done very well in the years since the HITECH Act, "But we're still at the stage where

technology often hurts rather than helps physicians providing better care." (Millard) One
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physician complained to him that in his EHR, "to order aspirin takes eight clicks; to order full-

strength aspirin takes 16."
(Millard) Slavitt said CMS is newly committed to taking a "user-

centered approach to designing policy."

Many clinicians, nurses and physicians still fall back on paper. Many hire scribes as an

intermediary as they are frustrated with their EHRs and would much rather just interact with

their patients. A study published this summer by the American Medical Association and the

American College of Physicians found that physicians are more frustrated with EHRs than they

were five years ago. (Millard) And forty-two percent of respondents said their EHR system’s

ability to improve efficiency was "difficult or very difficult." Some 72 percent said the same

about its ability to decrease workload. (Millard) From another HER Satisfaction Survey

conducted by HealthcareITNews.com many of the anecdotal feedback from the 400+ people wo

took the poll were filled with comments such as "not very intuitive," "cumbersome" and "too

many clicks". (Millard) A well-publicized New York Times Op-Ed entitled “In Age of Digital

Records Paper Still Carries Weight” by prominent New York MD Abigale Zuger further

tarnished the experience of EHRs and exposed to the masses the frustration with EHRs among

clinicians.

The Reasons:

Dan Norman, an internationally renown and published design guru, stated "The reasons for

the deficiencies in human-machine interaction are numerous. Some come from the limitations of

today's technology. Some come from self-imposed restrictions by the designers, often to hold

down cost. But most of the problems come from a complete lack of understanding of the design

principles necessary for effective human-machine interaction. Why this deficiency? Because
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much of the design is done by engineers who are experts in technology but limited in their

understanding of people." (Millard)

Health IT users, though desiring slick interface design, also know that their software and

systems have to comply with strict criteria from numerous federal regulatory agencies, so the

stakes and standards are a bit more stifling. As much as health care workers, clinicians, doctors

and nurses would love to be considered at the center of HER design, at the end of the day the a

vast majority of EHR software is developed by the IT industry, which means by software

engineers. Many of whom do not have any direct health care experience.

A recent study which was published in the Journal of the American Medical Informatics

Association took a look at user centered design processes at 11 unnamed vendors (those who

develop HER software). "Our analysis demonstrates a diverse range of vendors’ UCD practices

that fall into 3 categories: well-developed UCD, basic UCD, and misconceptions of UCD," wrote

researchers from MedStar Health's National Center for Human Factors in Healthcare, noting that

the latter category might refer, say, to the mistaken belief that responding to end-users' requests

and complaints qualifies as user-centered design. (Millard) On top of this many vendors “didn't

see the business case for investing in UCD processes.“ and “even found that some smaller EHR

vendors didn't even have any usability experts on their staff.” (Millard) According to Thomas

McGinn, MD, chair of medicine of Hofstra North Shore-LIJ-School of Medicine, states that "It is

believed that thoughtful systems engineering approaches, including consideration of user

experience and improvements in user interface, can greatly improve the ability of CDS tools to

reach their potential to improve quality of care and patient outcomes," (Millard) User experience

design has been overall ignored or, at best, misinterpreted and misunderstood within the

development of EHRs.
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Solutions? Addressing the Wicked Problem, the Stakeholder Environment, Integrating

User Centered Design Best-Practices, UCD Testing and Guidelines:

So why could this be? While there could have been an across the board lack of focus in

usability consideration during the rapid proliferation and adoption of EHRs it could also be

caused by a “poor translation of existing and well known best practices to ensure usability from

the field of design in healthcare” (Marcial) As evident by the Neehr Perfect EHR system that we

use at USD as an introduction to EHRs during our orientation (which itself is identical to the VA

Hospital VistA system) the overall aesthetic and usability result is one that un-fondly recalls the

days of tops MS-DOS (back in the Windows 3.11 days!). As the vast majority of EHR systems

run on Microsoft Windows (which dominates the commercial/enterprise realm) or a Linux

variant (a much more affordable alternative to Microsoft generally) of Windows this is

functional aesthetic that could perhaps almost could be forgiven. But considering the amazing

interfaces we see and use on a daily bases on our laptops, phones, tablets, apps, even

thermometers (the Nest digital thermometer for instance) why do EHRs seem to lag so

tremendously behind?

“Because EHRs often require complex technical integration, design and usability are often an

afterthought and fail to incorporate a robust user-centered design process or full scale usability

testing.” (Marcial) So perhaps the first step would be to address who the stakeholders are in

terms of EHR use and then consider usability? The first rule of any design process is to “know

your audience” but with health care that audience is very diverse. And a many software

developers who develop EHRs may not fully understand the scale and complexity of just how

many stakeholders are involved. Thus, according to Marcial, it makes sense to organize all of

these separate users into “stakeholder environments”. Included in these stakeholder

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environments are clinicians, vendors and systems engineers, patients and agencies and

governments.

Clinicians include doctors, nurses, physician assistants and just about anyone on the clinical

team are engaged with the EHR as well as interact directly with the patient. A common

complaint and concern with the clinicians I spoke to was that sometimes they were so focused on

their EHRs the patients would feel alienated, whether they be utilizing a desktop, laptop, or

tablet. In the future this interaction could be via a smartphone or even in virtual space, but for

now most eyes are glued far to long on the screen. Even though the doctor may be the primary

actor in the patient experience and may choose the actual EHR,“ much of the work involved in

creating and maintaining EHRs falls to other members of your clinical team. For a designer, this

means that understanding not just the different clinical roles, but also the workflow and the

(often hierarchical) work system are important elements of usability.” (Marcial)

In terms of vendors and system engineers who must accommodate, integrate and design for

and into as many disparate systems as possible as well as to integrate into existing systems in the

names of interoperability many large vendors such as a few mentioned earlier, Epic, Allscripts,

GE, and Cerner have emerged at attempting to begin to patch together all these daunting

concerns. So they have developed their own sets of protocols and systems that, much like a

square block in a round hole, does not accurately address the needs of a particular doctor,

specialist, clinic or hospital/HCO. Because software development is an ongoing and evolutionary

process these large vendors and engineers need to be looped in and also a stakeholder in the

process as it is imperative to have them understand the HER needs as much as the

aforementioned clinicians. “Unfortunately, because EHRs often require complex technical

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integration, design and usability are often an afterthought and fail to incorporate a robust user-

centered design process or full scale usability testing.’” (Marcial)

Patients must be considered in the design process and as stakeholders as it is their information

ultimately that becomes entered into the EHR. The record follows the patient wherever they go

(interoperability), it should result in “safe and effective treatment” (Marcial) and the information

should be “maintained and secure in a private manner, giving patients control of how this

information is shared”. (Marcial) This final point is even more prescient now than when first put

forth in 2014 due to the internet of things, everything now being connected and the many high

profile data breaches of personal information from hospitals and HCOs.

Finally agencies and governments are EHR stakeholders as they access data for policy

implementation and public health consideration and many times are not interoperable from

agency to agency or between agency into the rest of the entire healthcare system. “Using data

contained in an EHR to facilitate these public health activities can be a substantial benefit in

improving the health of an overall population.” (Marcial)

In addition to “knowing the audience” as described above, there are also four other steps that

constitute 5 key components of best-practice user centered design according to Ross Teague,

Ph.D., director user experience research at Allscripts, are: usability metrics, patterns and

standards, formative testing and summative testing.

With usability metrics it is paramount to define how you measure success, which can get

easily overlooked “to set specific, operationalized usability goals that design teams can track

throughout the development process. These measures can be objective (e.g., time on task, clicks,

errors) as well as subjective.” (Teague) In patterns and standards it is all about building

solutions based on known research and leveraging “human factors and cognitive psychology
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principles derived from evidence-based understanding of human performance, cognition and

accessibility” (Teague) with “standards specific to Health IT which are available to design teams

related to the presentation of the clinical data.” (Teague) Formative testing translates to formal,

moderated and regularly collected input from trial users. Summative testing is the evaluation of

the final “real world” product with users in a controlled and moderated manner. This final step is

the usability testing one would typically associate with product development, yet all four steps

that precede it also integrate many end users and collect feedback. All are critical for the success

of good user centric design.

“UCD (user centered design) is a critical component in software design. At its core, a good

UCD process is about involving users early and often, and using proven patterns in software

design. Vendors (and software engineers) need to pay heed as patient safety is at stake.”

(Teague)

One way to cohesively unite all the above is through some overarching guidelines. If this was

established then perhaps that would provide and user experience framework to design with and

thus can then bring all development into a general level of cohesion. This would then elevate the

overall level of design across the board. However, like everything else discussed previously,

agreeing upon a general set of guidelines is difficult with so many moving parts and the when

“the user environment is diverse and the tasks performed within the system range from simple to

highly specialized.”(Marcial)

One organization that is attempting this is National Center for Cognitive Informatics &

Decision Making in Healthcare (NCCD).” Their current working prototype focuses on the

essential human factors that affect perception, like seeking familiar patterns or our tendency to

seek out whole shapes rather than individual parts.“ (Marcial) The healthcare IT organization
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HIMSS also has tried to tackle HER usability with their research tending to focus on “healthcare

context.” (Marcial) Perhaps the AMIA and other professional, industry and governmental

organizations could release guidelines or standards as well? Or could there be a joint effort

amongst many of such organizations to tackle this problem? These would all be positives and

much more guidance via guidelines would be a major help in the overall better design practices

featured in the design of EHRs.

Conclusions:

With so many disparate and complex stakeholders the blame can’t fall squarely on the

shoulders of the software engineers and developers nor integrating usability testing as with

which group would one do the testing on? Each has different and unique needs. A doctor may

want better user experience for his swath of the functionality of the EHR while a government

agency would want complex data extraction for analysis to write policy and a patient just would

like their health information be presented in a way that is readable and makes sense to them.

Therefore this becomes a “wicked’ design problem with not any clear single solution.

“To be successful, UX designers need to bring both an understanding of good practice as well

as a willingness to apply design guidelines to specific problems encountered in

implementation.”(Marcial) Also, “usability methods need to consider the entire socio-technical

system, not just the individual user.”(Marcial)

"We are at the very early stages of the science of usability," wrote McGinn. "Much more

research and funding is needed in this area if we hope to improve the dissemination and

implementation of evidence in practice." (Miliard) We live in an era of sleek operating systems

like the macOS and Android, beautifully designed apps, elegant and intuitive entertainment
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navigations such as Netflix, gorgeous hardware such as Apple products and the Tesla Model S,

so it seems like the vast majority of the software and tech world has embraced design, UX and

what it can do in terms of making technology integrate more seamlessly into users’ lives and

enrich their experiences with it. Perhaps if EHR developers can address some of the design

pitfalls and follow some of the design principles elaborated upon here to bring the EHR

experience to that level of maturity, or at least catch up a bit more. Guidelines and

standardizations could be one way to get there. “Overall, there is much work to be done but

much opportunity to be found in the user design realms of all aspects of health care.” (Millard)
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Annotated References:

Health Information Technology. (n.d) In Wikipedia. Retrieved September 29, 2017,

from https://en.wikipedia.org/wiki/Health_information_technology

Seeks to define Health Information Technology. This definition is used a benchmark and
reference to build on and refer to.

Health Informatics. (n.d) In Wikipedia. Retrieved September 29, 2017, from

https://en.wikipedia.org/wiki/Health_informatics

Seeks to define Health Informatics. This definition is used a benchmark and reference to build on
and refer to.

Health Information Management. In Wikipedia. Retrieved September 29, 2017, from

https://en.wikipedia.org/wiki/Health_information_management

Seeks to define Health Information Management

This definition is used a benchmark and reference to build on and refer to.

Niles, N.J. (2015) Basics of the U.S Health System (2nd ed). Burlington MA: Jones & Bartlett
Learning

Textbook primer and survey of the U.S Health System.

Used as a reference for certain passages in defining aspects of informatics and electronic health
record systems.

National Library of Medicine. (2017) Retrieved from

https://www.nlm.nih.gov/hsrinfo/informatics.html

Great overview and definition of health care informatics as defined by the National Library of
Medicine. This definition is used a benchmark and reference to build on and refer to.
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User Experience Design. (n.d) In Wikipedia. Retrieved September 29, 2017, from
https://en.wikipedia.org/wiki/User_experience_design

Seeks to define User Experience Design.This definition is used a benchmark and reference to
build on and refer to.

Department of Health and Human Services. (n.d) Retrieved from

https://www.hhs.gov/

U.S Department of Health and Human Services main website. Used as a general reference.

Evans, Dwight C.; Nichol, W. Paul; Perlin, Jonathan B. (2006). "Effect of the implementation of
an enterprise-wide Electronic Health Record on productivity in the Veterans Health
Administration". Health Economics, Policy and Law. 1 (2): 163–9. Retrieved from
https://www.cambridge.org/core/journals/health-economics-policy-and-law/article/effect-of-the-
implementation-of-an-enterprisewide-electronic-health-record-on-productivity-in-the-veterans-
health-administration/0C8FEB82FF3ECFD2176EFF9B8E4EDEF0

Used as a reference to a study in an article quoted.

McDonald, Clement J.; Callaghan, Fiona M.; Weissman, Arlene; Goodwin, Rebecca M.;
Mundkur, Mallika; Kuhn, Thomson (November 2014). "Use of Internist's Free Time by
Ambulatory Care Electronic Medical Record Systems". JAMA Intern Med. 174 (11): 1860–1863.
Retrieved from http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1901114

Used as a reference to a study in an article quoted.

Top EMR Software. (n.d) Retrieved from

http://www.capterra.com/infographics/top-emr-software

A list of the most popular EHR software to be used as a reference for possible comparison from a
UX standpoint.

Millard, M (2016). Frustrations linger around electronic health records and user-centered design.
Retrieved from http://www.healthcareitnews.com/news/frustrations-linger-around- electronic-
health-records-and-user-centered-design

A user experience designer offers her take on the problems and pitfalls of EHRs and offers a few
solutions in alleviating some of the main problems.

Zuger, A (2015). In the age of digital records paper still carries weight. Retrieved
from https://well.blogs.nytimes.com/2015/12/14/in-age-of-digital records-paper-still-carries-
weight/?mcubz=0
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A rather popular New York Times health column contributor sheds some light on why EHRs
have not been popular in actual practice. Helps to illustrate why user centered design must
benefit the main end users: actual doctors and nurses.

Marcial, L (2014). Usability In Healthcare: A Wicked Problem. User Experience Magazine,

14(3).
Retrieved from http://uxpamagazine.org/usability-in-healthcare/

A user experience designer summarizes some of the key reasons why EHRs and software
systems in health care suffer from poor design. Also illustrates a few potential solutions.

Teague R (2016).How User Centered Design Can Improve EH Usability. Health IT Outcomes.
Retrieved from https://www.healthitoutcomes.com/doc/how-user-centered-design-can-improve-
ehr-usability-0001

Attempts to put forth potential solutions to the most common EHR usability issues by a lead user
experience designer at Allscripts.

Miliard, M (2013. Q&A: HxD co-founder Amy Cueva talks user-centered design. Healthcare IT
News.
Retrieved from http://www.healthcareitnews.com/node/444196

Breaks down and offers solutions for common EHR and general health care usability design
issues.
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